Rolling Wheels Training Center, LLC - BRC Application

Please print the application, then mail or fax to:

Rolling Wheels Training Center, LLC                              OFFICE/ FAX: 816-478-3677

4804B Noland Rd.

Kansas City, MO 64133

On-line registration and scheduling information available at www.rollingwheels.org.

Students are registered on a first come / first serve prepaid basis.

A 100% refund, less a $25.00 processing fee, will be issued if the registrant cancels the class MORE than 7 days in advance. Refunds will not be issued if the registrant cancels less than 7 days prior to the opening of the class. If the instructor determines the student is not eligible to complete the class or if the student voluntarily decides to leave the class, refunds will not be issued.

There will be a $10.00 fee to reschedule your class. You must reschedule more than 7 days in advance of your class.

If you are late for any class session, you will not be able to participate and you will forfeit your enrollment fee. If you do not show up for your class  you will forfeit your enrollment fee.

A list of items and clothing to bring to class will be sent with your confirmation letter.

EARLY REGISTRATION IS SUGGESTED. - Print your name as it would appear on your driver's license.

Name                                                                                                         Date of Birth                                         Sex________

Home/ Cell Phone                                                   Business Phone                                                          D.L. State_________                    

Address                                                                                                                                                                                               

City, State & Zip                                                                                                                                                                                 

Email Address:___________________________________________________________________

By signing below, I signify that I have read and understand the refund policy.

Applicant’s Signature: ______________________________________  Date: ________________

**If under the age of 18:  Parent’s Signature                                                                 

The cost for each Basic Rider Course is $215.00 .                        

Preferred class dates: 1^st choice: ______________________   2^nd choice: ______________________  

Method of payment: Check                                    Make Checks payable to: Rolling Wheels Training Center, LLC

Master Card                          Visa                         Discover _________ American Express___________

If you are using a credit card, please complete the following information.

Card Number                                                                                         VCODE                 Expiration Date                                   

Name as it appears on the card, if different from above                                                                                               

Total Amount: ________________

The issuer of the card identified on this item is authorized to pay the amount shown as Total. I promise to pay such Total subject to and in accordance with the agreement governing the use of such card.

Signature & Date  ______________________________________________